1. Genetic: you are born with certain predispositions
2. Environmental: where you were born and choose to live matters…if you don’t have clean drinking water, you will have a very difficult time staying healthy
3. Physical: your fitness, habits and hygiene play large roles
4. Psychological: the amount of stress you carry can make you ill

All of these elements operate from the patient’s standpoint. They basically have the same impact whether you live in Tokyo or a remote part of India. But the types of diseases vary by region and by levels of affluence. I have been to parts of the Middle East where the attitude is almost that if you don’t have diabetes, you are not fully participating in life. Given these commonalities, if you can fix healthcare problems at the bottom of the pyramid, you can learn how to lower the costs of providing healthcare solutions in developed nations too.

In both poor and affluent communities, healthcare costs swell because people don’t seek care early enough. Whether you ignore chest pains or an infection for too long, either way the cost of treatment will be exponentially higher than if you intervened early.

From a health information system standpoint, we need to think differently about how we identify, solve and treat healthcare problems. Most software systems in the healthcare world largely deal with transactions. They store medical records, lab results, and the like. This is very basic stuff, and not nearly the end goal.

In the future, the success of medical software anywhere in the world will hinge on its ability to proactively manage three things:

1. Disease
2. Diagnosis
3. Cure

For example, long before many diseases become critical (i.e., expensive to treat), there are changes within a person’s body and sometimes behavior. These changes are data. In fact, our bodies generate huge amounts of data, the vast majority of which our information systems ignore, until a disease reaches an expensive/critical stage. But the technology now exists to gather much of this data remotely – from lab-on-a-chip devices to medical tricorders. All we need is our systems to utilize this data properly.

To put this in simple terms, your physician should be able to alert you – not the other way around – when your body starts producing data of concern.

Now think back to the challenges of the poor. The greater our ability to remotely – and cost efficiently – monitor and treat a patient, the better our ability to lower healthcare costs worldwide. A physician in Manhattan or Mumbai should be able to help a patient in the middle of a poor, remote village…without ever leaving his or her office. This would greatly improve what we can do locally.

Medicine will always be about compassion and humans caring for humans, but we can’t deny that medicine has already also become a data science. We shouldn’t think about this in terms of one approach for the poor and another for the wealthy. We need to recognize that caring for the poor may benefit the wealthy more than they can possibly imagine today.

From remote monitoring to telemedicine to unmanned aerial delivery, all the technologies we need to deliver healthcare remotely via the Internet are available today. A variety of portable medical devices measure vital signs (temperature, heart rate, BP, BMI, oximetry and so on). Forget Skype, by next year Ostendo plans to have smartphones beam holograms just as R2-D2 did in Star Wars. Drones are being tested to deliver medical payloads to remote locations. Lab on a chip technology is more of a reality and can detect infectious diseases such as Malaria, Rotavirus, Influenza and so on. And digital stethoscopes, portable ultrasound machines, Internet-enabled otoscopes and retina cameras have been around for awhile.

All we need to do then is re-imagine healthcare delivery by connecting the dots. Let’s do so by first breaking up medicine into six discrete steps.

Six Steps of Medicine:

1. Underlying Indicators: This is when underlying indicators exist but symptoms haven’t manifested sufficiently to cause a patient to seek medical help. For example, a patient may be susceptible to heart disease (e.g. high cholesterol or high BP) but has never had symptoms such as fatigue or chest pain.

2. Visible Symptoms: Here, a patient suffers from mild to traumatic pain/discomfort owing to manifested symptoms. For example, fever is the most common symptom for a variety of diseases. At this step of the process, we do not know why a patient is suffering but we simply know that she is.

4. Core Consultation: A core consultation is when a doctor tries to arrive at a diagnosis from a variety of possible options. Lab tests/CT-scans/radiology tests and so on are also conducted to arrive at as precise a diagnosis as possible.

5. Assessment and Plan: By this step, a doctor makes a clear assessment of the medical problem and prescribes a plan. This involves medications (e.g. antibiotics for an infection) or referring the patient to another specialist (e.g. a cardiologist for further investigation) or further examination.

6. Follow Up: Assuming that the patient follows through with the plan, a follow-up visit assesses the progress made and determines if any changes might be required.

It is these steps that need to be re-imagined and executed remotely removing the need for the doctor and patient to be co-located.

5. EHR software: Other than storing medical records digitally, electronic health records can form a platform integrating data from doctors, patients, various medical devices and tests that make it possible to deliver healthcare remotely. This is the direction we are going with my company’s enki EHR platform.

6. Telemedicine software: Through technologies such as Skype, people are increasingly comfortable interacting over video. See Teladoc, American Well, Doctor on Demand, iKure. Ostendo develops a chip that can bring hologram technology to smartphones that would make a physician-patient virtual interaction more immersive.

7. Analytics software: Medicine is actively becoming a data science subject to analytics and therefore, protocol-driven medicine that can help curb disease at source. For example, population-scale deworming or screening for TB or vaccination protocols. Please see clinical decision support illustrations at Zynx, UpToDate, emerge, Isabel.

Several years ago, Parashuram, an attendant in our office lost his wife (who lived back home in a village) due to a gastrointestinal complication. I tried to get her medical records to doctors in the US but the diagnosis came in simply too late. She died a futile death – like several millions of patients who lack access to a timely diagnosis. That episode changed the direction of our company – it became obvious to me that health data needs to traverse easily and globally and an early diagnosis needs to be arrived at to avoid both costs and complexity.

Given all the technologies that are today available, imagine if a patient had a Health Box, a conceptualization that integrates everything to deliver healthcare remotely via the Internet.

A Simple Visualization: When in need of medical care, the patient or her family presses a button on the Health Box that alerts a contact center, which then patches on a nurse/doctor-on-call via a hologram. Per the doctor’s request, required accessories are plugged in to the Health Box to capture vital signs (e.g. BP, temperature, oximetry) and a physical exam is conducted (e.g. asking a patient to cough and placing the digital stethoscope on a patient’s chest or back). The data is seen in real-time via the EHR. The doctor makes a preliminary medical judgment regarding the next step of care. In case of emergencies, the contact center dispatches a drone to deliver a medical payload at the precise location of the Health Box.

The World Bank estimates that India loses 6% of its GDP (that’s $110B) due to premature deaths and preventable illnesses. This statistic wouldn’t be a whole lot better for any developing country. The developed world has a more nuanced problem – the US also suffers healthcare access, premature deaths and preventable illnesses, perhaps more than the developing world. At the crux of the problem is our inability to stop disease at source. This is what remote healthcare delivery does – encourages patients and healthcare providers to deal with medical problems before they explode in complexity and cost. It’s imperative that we figure this out.

Illustration developed by Swapnil Chafale for representational purposes. Credit as due to creators of respective public images.

1) A group consult is very effective, even emotionally. Unlike the private nature of healthcare delivery we are used to in the developed world, a group consult can actually be highly effective – even emotionally. It helps patients realize that others are sick too and they are not alone. This somehow converts the group consult into a more supportive environment that can possibly increase patient compliance.

To describe a group consult, a patient in Trincomalee, Sri Lanka sits in front of a Skype camera and interacts with doctor(s) in Ann Arbor, Michigan while other patients wait in the background and observe. The doctor(s) go over key vitals, past history, medication list, dosages and examine latest data available and note what’s changed from the last time. They ‘look’ at the patient via Skype, ask questions (some general) with the help of a translator/ medical assistant on the Sri Lanka side. Naresh and the medical students arrive at a consensus on what to do and then they move on to the next patient.

2) One hour together is a lot of time. When a group of doctors go over each case methodically for a group of patients, a lot is actually accomplished. Time is saved. There’s a unique sense of transparency – everyone knows what is being done. Unlike in private practice medicine, there’s a different sense of teamwork among the doctors and among patients. Learning occurs both ways.

3) The mind can’t really tell the difference. Video-conferencing even via a blurry medium (in this case Skype over a moderately paced Internet connection) is very effective. Patients (and doctors) forget after a point that no one is physically in front of each other. The doctors aren’t located in a formal office – in fact, some are on their bed, some in their studies, some in their kitchen. This provides a different sense of camaraderie and in a completely different way they are welcoming the patient into a personal space. After the initial minutes, the mind actually forgets what’s virtual and what’s real. The patient-doctor interaction can get as immersive and real as a video game.

4) Using evidence-based guidelines. Given the age of patients, the focus of care has been hypertension, followed by diabetes. Readings are captured by the assistant every other day and entered into the system. We are now programming enki EHR using JNC 8 guidelines for hypertension to automatically assist during care based on age and medical background of the patient. During the group consult, the guidelines keep care-givers in check based on evidence-based protocols. The evidence-based methodology provides great balance to the human interaction enabled through a virtual consult.

5) Sometimes, virtual is better than the real thing. This past week, Naresh shared the outcome of a short survey done amongst patients. They feel well taken care of and actually prefer ‘virtual care’ over a real one. While this may be early, it’s startling and very telling. But when you think about it, it’s actually not surprising. For some patients, the alternative to ‘virtual care’ is usually bad care or even no care.

*

Why this is the future and could change how healthcare is delivered

Every few decades, medicine undergoes a big shift – increasing access, life expectancy and so on. We are in the middle of another one – where medicine is becoming a more precise data science. There’s increasingly more data available about the human body – from a gross level (# of steps taken in a day to # of hours slept) to a deeper level (DNA testing to microbiome testing). Doctors are increasingly reliant on data (usually via lab tests) before making a medical judgment. Most data is always available via a patient’s electronic medical record. The ‘Internet of things’ is a very real trend (think, the Nest thermostat) and is becoming the ‘Internet of medical things’ where medical devices are Internet-enabled. Patients continue to live longer through the aid of medications and fixes at the hospital. Fewer and fewer doctors are getting into primary care where the basic flow chart of a patient’s diagnosis begins. Cost of care will continue to explode (even in the developing world) as science advances further within specialties and the influences of regulation, administration, insurance companies and law continue to rise.

The trends point to a world where access to quality and reliable healthcare will not just continue to be difficult but may also increase. The trends also point to a possible future where healthcare is accessible from anywhere through a mobile Internet connection with the aid of virtual consults and medical data through an EHR.

Last year, I went to Trincomalee on the east coast of Sri Lanka to volunteer at Grace Care Center, a wonderful orphanage and center for elders run by a friend and colleague Naresh Gunaratnam, MD from Ann Arbor, Michigan. I was part of a small group – we were mostly alumni from University of Michigan (from medicine, law, finance and business backgrounds) and one from Texas. Naresh suggested that we experiment with remote healthcare delivery/ management by rolling out enki EHR at the Center.

When an eye-camp was organized, we went through documenting medical charts of children from Grace and nearby orphanages electronically on enki. It was an interesting start because in a very short amount of time, we trained five or six senior kids at the home to start using the EHR. Two kids captured BMI, another documented demographics, and one girl Karthika (in the picture) who was training to become a dental assistant entered all the medical information. Each resident at the home had a paper medical chart documented previously by doctors volunteering/ visiting from University of Michigan. Over 2-3 days, the children and their local teachers entered all the information they had into enki – including medical data of the elders at the center.

A few months later, when I was in Ann Arbor, Naresh called me over one Saturday morning to watch a group Skype call. I saw 3-4 medical students in their respective homes, elders from Grace in Sri Lanka participating in a remote medical consultation under Naresh’s supervision. Someone who knew Tamil (the local language) would ask patients questions and translate – about pain, symptoms, behavior and so on. Then there would be a discussion amongst the group with Naresh asking the students probing questions. There were often references to previously documented electronic records of the patients. During an hour+ long call, one patient after the other received medical care remotely from Ann Arbor to Trincomalee. Everything was electronically documented in enki EHR. It was very satisfying to see remote healthcare delivery in action on a software that we created.

This morning I was pleasantly surprised to be copied on an email that the students were mailing each other – it said ‘enki training video in Tamil’. One or more of the medical students from UM made a basic video on how to document medical records in enki EHR in the local language, Tamil. Here’s that video.

Professor C.K. Prahalad (from whom I learnt anything I needed to learn from a business school – all outside of class) often used to talk about weak signals that would give a glimpse into the future – these usually amplify over time and become dominant trends. I remembered him this morning. On the face of it, the experiment in Sri Lanka may seem like a simple video conference, followed by documentation of patient records, training of medical students and localization of a software program. But it gives a peek into the future of how medical training could be imparted and how healthcare could be delivered – remotely, virtually, without regard to location, perhaps on demand. Electronic health records are really not an end in themselves – they are simply the building blocks that would allow for treating patients anywhere, anytime with the aid of data.